Journal Article

Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial

Huber, Peter R, Jaccard-Stolz, Daiana, Bingisser, Roland, Müller, Beat, Tamm, Michael, Christ-Crain, Mirjam, Gencay, Mikael M

2004

Overview

Lower respiratory tract infections are often treated with antibiotics without evidence of clinically relevant bacterial disease. Serum calcitonin precursor concentrations, including procalcitonin, are raised in bacterial infections. We aimed to assess a procalcitonin-based therapeutic strategy to reduce antibiotic use in lower respiratory tract infections with a new rapid and sensitive assay. 243 patients admitted with suspected lower respiratory tract infections were randomly assigned standard care (standard group; n=119) or procalcitonin-guided treatment (procalcitonin group; n=124). On the basis of serum procalcitonin concentrations, use of antibiotics was more or less discouraged (<0·1 μg/L or <0·25 μg/L) or encouraged (≥;0·5 μg/L or ≥0·25 μg/L), respectively. Reevaluation was possible after 6–24 h in both groups. Primary endpoint was use of antibiotics and analysis was by intention to treat. Final diagnoses were pneumonia (n=87; 36%), acute exacerbation of chronic obstructive pulmonary disease (60; 25%), acute bronchitis (59; 24%), asthma (13; 5%), and other respiratory affections (24; 10%). Serological evidence of viral infection was recorded in 141 of 175 tested patients (81%). Bacterial cultures were positive from sputum in 51 (21%) and from blood in 16 (7%). In the procalcitonin group, the adjusted relative risk of antibiotic exposure was 0·49 (95% CI 0·44–0·55; p<0·0001) compared with the standard group. Antibiotic use was significantly reduced in all diagnostic subgroups. Clinical and laboratory outcome was similar in both groups and favourable in 235 (97%). Procalcitonin guidance substantially reduced antibiotic use in lower respiratory tract infections. Withholding antimicrobial treatment did not compromise outcome. In view of the current overuse of antimicrobial therapy in often self-limiting acute respiratory tract infections, treatment based on procalcitonin measurement could have important clinical and financial implications. Published online Feb 10, 2004. http://image.thelancet.com/extras/04art1162web.pdf

• Publisher: Elsevier Ltd,Lancet,Elsevier Limited
• Subject: Acute Disease / Aged / Anti-Bacterial Agents - therapeutic use / Antibiotics / Antiinfectives and antibacterials / Asthma / Bacteria / Bacterial diseases / Bacterial diseases of the respiratory system / Bacterial infections / Bacterial Infections - blood / Bacterial Infections - drug therapy / Biological and medical sciences / Blood / Body temperature / Bronchitis / Bronchitis - blood / Bronchitis - drug therapy / Calcitonin / Calcitonin - blood / Calcitonin Gene-Related Peptide / Chronic obstructive pulmonary disease / Clinical trials / Diagnostic systems / Drug resistance / Drug therapy / Drug Utilization Review / Dyspnea / Emergency medical care / Evidence-based medicine / Family medical history / Female / Hospitals / Human bacterial diseases / Humans / Infections / Infectious diseases / Intensive care / Laboratories / Lung diseases / Male / Medical sciences / Middle Aged / Motivation / Obstructive lung disease / Patients / Pneumonia / Pneumonia - blood / Pneumonia - drug therapy / Procalcitonin / Protein Precursors - blood / Proteins / Pulmonary Disease, Chronic Obstructive - blood / Pulmonary Disease, Chronic Obstructive - drug therapy / Quality / Respiratory diseases / Respiratory tract / Respiratory tract diseases / Respiratory tract infection / Respiratory Tract Infections - blood / Respiratory Tract Infections - drug therapy / Respiratory Tract Infections - microbiology / Single-Blind Method / Sputum / Subgroups / Treatment Outcome / Viral infections